WHITE PAPER

Defining Workplace Wellness ProgramsA Rapid Systematic Review

Julie A. Hind and Michael J. Rouse

Ivey Business School at Western UniversityLondon, Ontario, Canada

Copyright ©Ivey Business School, 2014

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Objectives: We review the current literature on workplace wellness programs and develop a definition to facilitate shared understanding and comparability for future research.

Methods: A rapid systematic review methodology is utilized to drive for timely information and relevance, without sacrificing rigour.

Results: We develop a synthesized definition of workplace wellness to help facilitate communication and comparability of research. Our review flags up important elements common to successful workplace wellness programs and highlights areas for future research.

Conclusions: The accumulation of evidence on the outcomes, impacts, content and processes of wellness programs all require more research and more rigorous research. A shared definition is a good starting point.

Introduction

The literature on workplace wellness programs dates back to as long as three decades ago. Nonetheless, recent literature is still debating whether or not employers should implement such programs. Although the accumulation and synthesis of evidence has been slow, employers’ interest in these programs is on the rise (Goetzel & Ozminkowski, 2008). A major barrier to the accumulation of evidence lies in the absence of a consistent definition for workplace wellness programs. Without one, the evaluation and comparison of such programs becomes problematic. The purpose of this paper is to review the current literature and to develop a definition in order to facilitate a shared understanding of workplace wellness programs. The aims were to identify: (1) the key features of workplace wellness programs (2) the gaps in the literature (3) a definition for workplace wellness programs and (4) implications for research and practice.

Methods

Rapid Reviews Traditional systematic reviews require a timeframe of at least six months to two years to complete (Khangura, Konnyu, Cushman, Grimshaw, & Moher, 2012). However, policymakers, decision makers and stakeholders often require

timely synthesis of knowledge in an area to facilitate evidence-based decision-making (Khangura et al., 2012; Ganann, Ciliska, & Thomas, 2010). Rapid review methodology has emerged as a means to address this need, and is often used in healthcare settings (Ganann et al., 2010). Rapid systematic reviews are literature reviews that accelerate or streamline traditional systematic review methods (Ganann et al., 2010). Rapid reviews do not employ exhaustive search strategies and often place emphasis on locating and summarizing evidence from relevant and high-quality systematic reviews (Khangura et al., 2012). Watt et al. (2008) found that although the scope of rapid reviews is limited, they can provide adequate advice for decision-makers. The aim of a rapid review is to provide an overview of the evidence

available regarding a particular topic and to give a sense of the volume and direction of the evidence (Khangura et al., 2012). Given the drive for timely information, a rapid systematic review was conducted.

Search Strategy A search was conducted for research articles published in peer-reviewed journals using PubMed and EBSCO Business Source from January 2000 through July 2013. Search terms included combinations of “workplace wellness program”, “corporate wellness”, “health program”, “health promotion”, “worksite”, “intervention”, “occupational health”, “employee health”, “disease management”, “absenteeism”, and “stress”. Hand-searching of high-quality reviews was also employed in an attempt to uncover additional articles.

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Consistent with rapid review methodology, a focus was placed on locating high-quality systematic reviews. No restrictions were placed on geographical location. All publications were English-language articles. The search yielded 13 relevant articles ranging from 2001 to 2013: Baicker, Cutler, & Song, 2010; Cancelliere, Cassidy, Ammendolia, & Côté, 2011; Goetzel & Ozminkowski, 2008; Goetzel et al., 2007; Goetzel, Guindon, Turshen, & Ozminkowski, 2001; Grossmeier, Terry, Anderson, & Wright, 2012; Lerner, Rodday, Cohen, & Rogers, 2013; Linnan et al., 2008; Osilla et al., 2012; Pelletier, 2005; Pelletier, 2009; Pelletier, 2011; Terry, Seaverson, Grossmeier, & Anderson, 2008.

Definitions A review of the current literature of workplace wellness programs brings to light a lack of consensus. To start, the studies use a plethora of terms to refer to these programs including, workplace wellness programs, population health management programs, workplace health promotion programs, worksite wellness programs, worksite health management programs, worksite-based health promotion and disease management programs, and health and productivity management programs. This brings into question the definition of workplace wellness programs and whether these terms can be used

interchangeably. We reviewed the definitions provided in each of the review articles (see Table 1 -- Definitions). Four of the studies did not provide an explicit definition (Baicker et al., 2010; Linnan et al., 2008; Terry et al., 2008; Goetzel et al., 2001). Pelletier (2011) defines comprehensive worksite-based health promotion and disease management programs as, “those programs that provide an ongoing, integrated, program of health promotion and disease prevention that integrates the particular components into a coherent, ongoing program that is consistent with corporate objectives and includes program evaluation”. Whereas Goetzel & Ozminkowski (2008) defines worker health promotion programs as, “employer

Table 1– Defining Workplace Wellness Programs Author Definition Cancelliere et al., 2011

Health promotion in the workplace is defined as preventing, minimizing and eliminating health hazards, and maintaining and promoting work ability.

Goetzel & Ozminkowski, 2008

Work site health-promotion programs are employer initiatives directed at improving the health and well-being of workers and, in some cases, their dependents. They include programs designed to avert the occurrence of disease or the progression of disease from its early unrecognized stage to one that's more severe.

Goetzel et al., 2007

Health and productivity management programs encompass worksite-based initiatives that include health promotion (eg, health management or wellness programs); disease management (eg, screening, care management, or case management programs); demand management (eg, self-care, nurse call line programs); and related efforts to optimize employee productivity by improving employee health.

Grossmeier et al., 2012

Comprehensive population health management programs include targeted disease management coaching, targeted lifestyle management coaching, and population-wide health awareness programs.

Lerner et al., 2013 Worker health promotion programs are opportunities available to employees at the workplace or through outside organizations to start, change, or maintain health behaviors.

Osilla et al., 2012 Comprehensive worksite wellness programs have multiple wellness components focused on health promotion or disease prevention

Pelletier, 2005; Pelletier, 2009; Pelletier, 2011

Comprehensive worksite-based health promotion and disease management programs refer to those programs that provide an ongoing, integrated, program of health promotion and disease prevention that integrates the particular components (ie, smoking cessation, stress management, lipid reduction etc.) into a coherent, ongoing program that is consistent with corporate objectives and includes program evaluation.

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initiatives directed at improving the health and well-being of workers and, in some cases, their dependents. They include programs designed to avert the occurrence of disease or the progression of disease from its early unrecognized stage to one that’s more severe.” Although the terms vary across the studies, there are some consistencies in their definitions. The major finding is that the definitions typically include activities related to health promotion and disease management. The World Health Organization (2013) defines health promotion as, “the process of enabling people to increase control over, and to improve, their health. It moves beyond a focus on individual behaviour towards a wide range of social and environmental interventions”. On the other hand, disease management is defined as, “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (Care Continuum Alliance, 2013). We must recognize that these two components are not mutually exclusive. For example, diet and exercise interventions in the workplace can be classified as health promotion efforts, however, for someone with type II diabetes, these same efforts could also be considered as disease management. Nonetheless, health promotion and disease

management activities are central aspects of workplace wellness programs.

Program Goals A consistent finding across the literature is that workplace wellness programs are implemented by employers with the goal of improving the health of their employees (Goetzel & Ozminkowski, 2008; Osilla et al., 2012; Cancelliere et al., 2011; Goetzel et al., 2007; Lerner et al., 2013). Employers often seek the direct and indirect benefits associated with improved health such as reduced health care costs (Baicker et al., 2010; Grossmeier et al., 2012; Linnan et al., 2008; Osilla et al., 2012; Goetzel et al., 2007; Lerner et al., 2013), reduced absenteeism (Baicker et al., 2010; Linnan et al., 2008; Osilla et al., 2012), reduced turnover (Baicker et al., 2010), increased presenteeism (Cancelliere et al., 2011), and increased productivity (Lerner et al., 2013). Linnan et al. (2008) found that 44 percent of sites expected a positive return on investment (ROI) for their program.

Focus of Intervention The programs’ foci of intervention were reported by most of the studies. Weight loss and exercise, diet and nutrition, and smoking cessation programs are among the most frequent interventions (Baicker et al., 2010; Goetzel et al., 2007). However, variations in

program focus are reported by many reviews (Linnan et al., 2008; Cancelliere et al., 2011). Additional research is needed to address the important question of which program foci are most effective, however the answer is likely to differ depending on the industry in which a business operates (Baicker et al., 2010). Recent research is beginning to support the practice of addressing multiple risk factors, as Baicker et al. (2010) found that 75% of programs addressed multiple risk factors and Goetzel & Ozminkowski (2008) reported that a key component of successful programs was wellness program design that addressed multiple risk factors.

Modality The method of delivery is an important consideration in workplace wellness programs. Baicker et al. (2010) and Osilla et al. (2012) found the top three modalities included self-help or educational materials, health risk assessments, and individual or group counseling. The literature reports a wide range of modalities including the use of health professionals, online material, off-site facilities, and environmental changes. Goetzel & Ozminkowski (2008) reported that most successful programs offer multiple modalities. Likewise, Terry et al. (2008) found 67% of best practice programs used multiple modalities. However, it is not clear what relative impact different engagement modalities

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have on program effectiveness. More research is required in this area to determine which modalities are most effective (Terry et al., 2008).

Incentives Many of the studies discussed the use of incentives within workplace wellness programs. Incentives can be used for enrollment, participation, survey completion, compliance with behaviour change recommendations, or achievement of certain health goals (Osilla et al., 2012; Goetzel & Ozminkowski, 2008). Baicker et al., (2010) and Linnan et al., (2008) found of all the studies included in their reviews only 31% and 26% respectively used incentives. Osilla et al., (2012) and Terry et al., (2008) reported much higher rates of incentive use. Osilla et al., (2012) found 70% of comprehensive worksite wellness programs used incentives and Terry et al., (2008) found 100% of best

practice programs used incentives. There is some support that incentives help improve the success of workplace wellness programs. Goetzel & Ozminkowski (2008) found that increasing incentives at $100 intervals results in incremental 10% improvements in health risk assessment and program participation. No other research was reported that evaluated the impact of incentive use. Although incorporating incentives into program design seems promising, it is not regarded as a critical component of programs but may be helpful in increasing program participation and outcomes.

Key Success Factors Nine studies discussed the key components found in successful programs (Cancelliere et al., 2011; Linnan et al., 2008; Goetzel & Ozminkowski, 2008; Terry et al., 2008; Goetzel et al., 2007; Pelletier, 2005; Pelletier, 2009; Pelletier, 2011; Goetzel et

al., 2001). Table 2 displays the recommendations found in each study. The top five components recommended for successful programs are:

organizational leadership health-risk screening individually tailored

programs supportive workplace

environment and culture comprehensive program

design.

Although each of these elements were found to contribute to successful programs, no one component has been proven to be essential to workplace wellness programs. For this reason, none of these factors will be incorporated into a workplace wellness program definition. However, it is important to research what contributes to successful programs as well as what barriers to success exist.

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Table 2 – Key Success Factors

Cancelliere, et al., 2011

Linnan et al., 2008

Goetzel & Ozminkowski,

2008 Terry et al.,

2008 Goetzel et al., 2007

Pelletier, 2005; Pelletier, 2009; Pelletier, 2011

Goetzel et al., 2001

Organizational leadership

Health-risk screening

Individually tailored programs

Supportive workplace environment and culture

Comprehensive program design

Program champion

Effective communications about program, and about successful outcomes to key stakeholders

Integration into org structure and operations

Alignment between the program and broader objectives

Achieve higher participation rates

Data collection and rigorous evaluation of programs

Address multiple risk factors

Variety of engagement modalities

Use of incentives

Assure sufficient duration

Provide easy access to programs and effective follow-up

Linkage to related programs

Support self-care and self-management

Vendor integration

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Measured Outcomes The majority of reviews reported that programs were evaluated based on their ability to meet goals (above), such as improved health, reduced health care costs, reduced absenteeism, reduced turnover, decreased presenteeism, and increased productivity (Baicker et al., 2010; Grossmeier et al., 2012; Cancelliere et al., 2011; Linnan et al., 2008; Osilla et al., 2012; Goetzel et al., 2007; Lerner et al., 2013). A lack of standardization in calculating these outcome metrics exists, which presents a barrier to developing a critical mass of high-quality research (Lerner et al., 2013). Linnan et al., (2008) and Goetzel et al., (2007) also reported that studies were evaluated on employee feedback and participation levels. Rigorous evaluation of programs was found as a key success factor (Goetzel et al., 2007). However, no particular, singular, outcome metric is pertinent to evaluate programs across the board and so businesses should use key metrics that are the most significant to their business (Goetzel et al., 2007).

Defining Workplace

Wellness Programs Incorporating the knowledge gathered from reviewing the literature, the following definition for workplace wellness programs is proposed:

Workplace wellness programs are workplace-based programs that incorporate health promotion and disease prevention activities with the goal of improving the health of employees. The definition also encapsulates the goal of wellness and the expectation that flows from this is that employers will also achieve benefits, such as reduced health care costs, absenteeism and turnover, decreased presenteeism and increased productivity, which could serve as metrics for program evaluation. Workplace wellness programs most often address multiple foci and employ multiple modalities and may potentially use incentives as a means of improving program participation and outcomes.

Conclusion: Implications

for Research and Practice The proposed definition will help to address the clear lack of consensus of what constitutes workplace wellness programs. A shared understanding of this concept will facilitate the accumulation of evidence in a coherent way. Additional gaps in research identified throughout this review include the relative effectiveness of different intervention foci and modalities as well as the use of incentives. Previous research has aimed to address the question of whether or not workplace wellness programs

should be instituted. Instead, research should begin to investigate how programs should be designed, implemented and evaluated to achieve the best results (Cancelliere et al., 2011). A focus needs to be placed on empowering businesses with the evidence needed to develop and implement successful programs. Education, communication and dissemination efforts need to be improved to inform employers and encourage the implementation of successful programs (Goetzel et al., 2007). Furthermore, employers need to be provided with effective tools and resources to support their efforts (Goetzel et al., 2007). Tools to assist employers calculate their unique ROI or benchmark their efforts against best practices can help research inform practice (Goetzel et al., 2007).

Limitations The use of rapid review methodology may introduce selection bias, publication bias and language of publication bias, as search strategies were not comprehensive. Furthermore, the included reviews reported small sample sizes due to the lack of high-quality control trials and therefore brings into question the generalizability of their findings.

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References Baicker, K., Cutler, D., & Song, Z. (2010). Workplace Wellness Program Can Generate Savings. Health Affairs, 29(2),

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Cancelliere, C., Cassidy, D. J., Ammendolia, C., & Côté, P. (2011). Are workplace health promotion programs effective at improving presenteeism in workers? A systematic review and best evidence synthesis of the literature. BMC Public Health, 11:395.

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Goetzel, R. Z., Shechter, D., Ozminkowski, R. J., Marmet, P. F., Tabrizi, M. J., & Roemer, E. C. (2007). Promising Practices in Employer Health and Productivity Management Efforts: Findings From a Benchmarking Study. Journal of Occupational and Environmental Medicine, 49:2, 111-113.

Goetzel, R. Z., Guindon, A. M., Jeffery, T. I., & Ozminkowski, R. J. (2001). Health and Productivity Management: Establishing Key Performance Measures, Benchmarks, and Best Practices. Journal of Occupational and Environmental Medicine, 43:1, 10-17.

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Michael J. Rouse, PhD

Strategy & Organization Professor, Ivey Business School Academic Director, Healthcare Management Executive MBA, China Leader, Executive Client Projects, India Ivey Business School at Western University

Cross-appointment: Epidemiology & Biostatistics, SSchulich Medical School, Western University

1255 Western RoadLondon, ON, Canada, N6G 0N1mrouse@ivey.uwo.ca519.661.4026